A 48-year-old male presents with 2 weeks of severe right lower quadrant abdominal pain and inguinal pain. The patient had similar pain 2 weeks ago, was referred to a surgery clinic, but was lost to follow up. The pain has been progressively worsening over the last 2 days. It’s now severe, associated with nausea and vomiting, does not radiate, and it is worsened with coughing and sneezing. He also endorses polyuria for an unknown length of time. His last bowel movement was 3 days ago. He denies diarrhea, constipation, hematochezia, melena, dysuria, hematuria, or recent trauma.
The CT results demonstrated Amyand’s hernia, which occurs when the appendix herniates through the inguinal ring and becomes incarcerated. Amyand’s hernia makes up less than 1% of inguinal hernias; and of all cases of appendicitis, only 0.1% present as Amyand’s hernia.
Pathological examination of the appendix found dark red and hemorrhagic segments consistent with incarceration. Definitive management is surgical removal of the appendix, and surgical consultation was immediately sought.
Take Home Points
In the context of abdominal and pelvic pain, appendicitis is always on the differential.
Appendicitis doesn’t necessarily need to present acutely.
Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.